Healthcare Provider Details

I. General information

NPI: 1851240915
Provider Name (Legal Business Name): KOHL KIMOTO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E 10TH AVE STE 308
EUGENE OR
97401-3687
US

IV. Provider business mailing address

475 RIVERVIEW BLVD
SPRINGFIELD OR
97477-3869
US

V. Phone/Fax

Practice location:
  • Phone: 833-646-9633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10357449-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10056381
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP70097585
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: